Choline: The essential but forgotten nutrient

This article was originally published November 2, 2017 inThe Seattle Times.
by Carrie DennentSpecial to The Seattle Times

On Nutrition

Perhaps it’s because you don’t see it on nutrition labels yet, but choline — an essential nutrient from conception through old age — tends to be tragically overlooked. According to data from the National Health and Nutrition Examination Survey, only 1 in 10 of us get enough choline, and those percentages drop among women during pregnancy — right when they need it most.

Choline is neither a vitamin nor a mineral, although it’s loosely related to the B-vitamin family. Our bodies make some choline, but not enough to meet our needs, which is why the Institute of Medicine classified it as an essential nutrient in 1998. Last year, the Food and Drug Administration (FDA) set a daily recommended intake of 550 milligrams (mg) per day for men and 425 mg per day for women — with 450 mg during pregnancy and 550 mg during breast-feeding.

Why does this matter? Because choline is vital for brain development before birth and during infancy, and choline deficiency can pose significant health risks in adults as well. Here’s what you need to know.

Choline and pregnancy

Choline is as important as folic acid during pregnancy. “For fetal brain development, choline is a critical nutrient,” said Stephen Zeisel MD, Ph.D., professor of nutrition and pediatrics at University of North Carolina, Chapel Hill. “If it’s not there at the right time, the baby’s brain doesn’t form correctly.”

Zeisel and Marie A. Caudill, Ph.D., RD, a nutrition professor at Cornell University, both spoke about choline at the Academy of Nutrition and Dietetics’ annual Food & Nutrition Conference & Expo in Chicago last month. Cau­dill says that our national deficiency is concerning, because data suggest that the new daily recommended intakes may be too low.

During pregnancy, extra maternal choline reduces a woman’s risk of developing pre-eclampsia or having a baby with neural-tube defects, and babies born to moms who got ample choline have lower levels of the stress hormone cortisol. Caudill said these “choline babies” may have a lower lifetime risk of developing stress-related diseases like high blood pressure, type 2 diabetes and depression. After birth, choline continues to be vital for normal brain development in the infant and young child.

Recent research suggests that only 8.5 percent of pregnant women meet the daily choline recommendations, but as of last year, none of the top 25 prenatal multivitamins contained the recommended 450 mg dose of choline for pregnant women. This prompted the American Medical Association (AMA) to recently call for increasing the amount of choline in prenatal vitamins.

“They recognize the importance of choline during pregnancy, and are encouraging manufacturers to come up with ways to get choline in these vitamins,” Caudill said.

Both Thomas Druke and Jessica Myers of Balchem, the manufacturer of VitaCholine, a brand of choline used in supplements and fortified foods and beverages, say they think it will be interesting to see how the supplement industry responds to the recent AMA statement. Myers said that the infant-formula and sports-nutrition markets currently have the strongest awareness of choline’s importance.

Druke said that adding choline to multivitamins has a few challenges, including the fact that it takes up a lot of “real estate” in a pill but that the challenges are not insurmountable. He said separate choline supplements are another option, and that a 110 mg supplement during pregnancy would be “a good place to start to fill the gaps.”

Beyond pregnancy: Age, gender and genetics

Children tend to get enough choline because they drink milk — but few adults do. This may be a minor issue, or a major one, depending on your gender, age and genetic makeup. Also, research suggests shows that about 10 percent of people may need 850 mg per day.

“Young women may or may not need choline, but men and older women definitely do,” Zeisel said. Why? The gene for making your own choline is switched on by the hormone estrogen, so some younger women are able to turn that gene on and make their own choline. However, men and postmenopausal women don’t have enough estrogen to produce adequate choline. Evolutionarily, this makes sense due to the need for choline during pregnancy.

That said, almost half of all premenopausal women do need extra choline from diet or supplements — especially during pregnancy — because they have a genetic variation that disables their “estrogen switch,” Zeisel said. This is more likely for women with European ancestry. Additionally, about 5 percent of men of European ancestry have a genetic variation that means their sperm “don’t swim well” when they are choline deficient.

Choline deficiency can increase the risk of developing fatty liver, and, when accompanied by certain genetic variations, may increase the risk of breast cancer in women and prostate cancer in men. That’s the bad news. The good news is that if you get enough choline from diet or supplements, your genes, gender, or age don’t matter. So what’s stopping roughly 90 percent of the population from meeting the daily recommendations?

Where we get choline

Choline is naturally found in egg yolks, salmon and other fish, meat, poultry, milk and dairy foods, and soybeans. The best food source of choline is eggs, with one large egg providing a quarter of the daily choline needs for a pregnant woman and more than half the needs of a 4- to 8-year-old child.

Zeisel said our choline intake started to drop in the 1970s with the advice to reduce dietary cholesterol. “Many adults are avoiding foods that contain choline because they are avoiding cholesterol. It gets a lot harder to get enough choline if you’re not drinking milk and eating eggs and meat.”

Vegans — and vegetarians who avoid eggs — need to be more thoughtful about getting the amount they need. Brussels sprouts, broccoli, cauliflower, soymilk, wheat germ, peanuts and many types of beans have modest amounts. However, Caudill said it’s difficult to eat enough of these foods to meet recommendations without some help from supplements.

Carrie Dennett, MPH, RDN, CD is a registered dietitian nutritionist at Menu for Change and Nutrition By Carrie. Visit her at nutritionbycarrie.com or follow her on Twitter at @CarrieDennett